Presentation, Diagnosis and Treatment Delays in Breast Cancer Care and Their Associations in Sri Lanka, a Low-resourced Country

AIMS

Delays in breast cancer care, one important attributable factor for breast cancer being diagnosed at advanced stages, are not systematically studied in many countries. This study assessed the magnitude and factors associated with delays in breast cancer care in Sri Lanka, from symptom detection to treatment initiation.

MATERIALS AND METHODS

We interviewed 800 consecutively sampled female breast cancer patients, diagnosed within the last 12 months, using context-specific questionnaires and medical records. We defined the cut-off times for delays using international guidelines and features of the national health system and care-seeking patterns in the country. Delays were estimated as proportions with 95% confidence intervals and presented for: (i) presentation delay; (ii) diagnosis delay and (iii) treatment delay. We looked at how sociodemographic and healthcare availability and accessibility at the individual level were associated with delays using multivariate logistic regression, with a P value of 0.05 to define statistical significance.

RESULTS

Nearly two-thirds of patients reported a presentation delay (63.3%, 95% confidence interval 59.9-66.6%). A diagnosis delay (36.7%, 95% confidence interval 33.4-40.0%) was also seen among one-third, whereas treatment delays (13.2%, 95% confidence interval 10.8-15.5%) were less common. Low family monthly income (odds ratio 6.3; 95% confidence interval 4.2-9.3) and poor knowledge on breast cancer (odds ratio 2.7; 95% confidence interval 1.8-3.8) were associated with presentation delay. Poor health literacy (odds ratio 1.7; 95% confidence interval 1.1-2.7) and the need to make more than two visits to the first contact health provider prior to diagnosis (odds ratio 7.2; 95% confidence interval 4.6-11.1) were associated with diagnosis delays, whereas directly contacting an appropriate specialised health provider once the lump was detected reduced diagnosis delay (odds ratio 0.3; 95% confidence interval 0.2-0.4). Having undergone a core biopsy (odds ratio 0.5; 95% confidence interval 0.3-0.8) and having a mammogram (odds ratio 0.6; 95% confidence interval 4.7-32.7) reduced the likelihood of treatment delays.

CONCLUSIONS

Our study findings show that delays in breast cancer care in Sri Lanka are much lower than those in other lower-middle income countries. However, there is significant room for improvement, especially in relation to the excellence in quality of care, such as improving access to mammography services. Periodical estimation of breast cancer delays enabling temporal comparisons will probably provide useful information to policy makers in improving care delivery for breast cancer patients and, hence, is recommended. Such future assessments designed for comparisons between different treatment modalities would provide more information to assist policy decisions in care improvement.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Genetic and other risk factors for suicidal ideation and the relationship with depression

BACKGROUND

There is a genetic contribution to the risk of suicide, but sparse prior research on the genetics of suicidal ideation.

METHODS

Active and passive suicidal ideation were assessed in a Sri Lankan population-based twin registry (n = 3906 twins) and a matched non-twin sample (n = 2016). Logistic regression models were used to examine associations with socio-demographic factors, environmental exposures and psychiatric symptoms. The heritability of suicidal ideation was assessed using structural equation modelling.

RESULTS

The lifetime prevalence of any suicidal ideation was 13.0% (11.7-14.3%) for men; 21.8% (20.3-23.2%) for women, with no significant difference between twins and non-twins. Factors that predicted suicidal ideation included female gender, termination of marital relationship, low education level, urban residence, losing a parent whilst young, low standard of living and stressful life events in the preceding 12 months. Suicidal ideation was strongly associated with depression, but also with abnormal fatigue and alcohol and tobacco use. The best fitting structural equation model indicated a substantial contribution from genetic factors (57%; CI 47-66) and from non-shared environmental factors (43%; CI 34-53) in both men and women. In women this genetic component was largely mediated through depression, but in men there was a significant heritable component to suicidal ideation that was independent of depression.

CONCLUSIONS

These are the first results to show a genetic contribution to suicidal ideation that is independent of depression outside of a high-income country. These phenomena may be generalizable, because previous research highlights similarities between the aetiology of mental disorders in Sri Lanka and higher-income countries.

Screening patients with tuberculosis for diabetes mellitus in Ampara, Sri Lanka

Given the well-known linkage between diabetes mellitus (DM) and tuberculosis (TB), the World Health Organization recommends bidirectional screening. Here we report the first screening effort of its kind from a chest clinic in the Ampara district of Sri Lanka. Of 112 TB patients registered between January 2013 and October 2014, eight had pre-existing DM. Of those remaining, 83 (80%) underwent fasting plasma glucose testing, of whom two (2%) and 17 (20%) were found to have diabetes and impaired fasting glucose, respectively. All of these were enrolled in care. Screening TB patients for DM was found to be feasible at the district level. Further studies at the provincial/country level are required before making any decision to scale up bidirectional screening.

Characteristics and outcomes of tuberculosis patients who fail to smear convert at two months in Sri Lanka

SETTING

Five districts in Sri Lanka.

OBJECTIVES

To determine: 1) the proportion of sputum smear-positive pulmonary tuberculosis (PTB) cases who failed to smear convert at 2 months, 2) their management, and 3) whether baseline characteristics and final treatment outcomes were different from those who did smear convert.

DESIGN

Cross-sectional retrospective review of medical files, tuberculosis (TB) registers and TB treatment records of new smear-positive PTB patients registered from January to December 2010.

RESULTS

Of 925 patients, 840 were available to submit sputum at 2 months, of whom 137 (16%) were smear-positive. Baseline sputum smears showing 3+ acid-fast bacilli and missing doses of anti-tuberculosis drugs during the initial phase of treatment were significantly associated with being smear-positive at 2 months. Management was poor: of 137 patients, 46 (34%) submitted sputum for culture and drug susceptibility testing and Mycobacterium tuberculosis was cultured in six cases; 120 (88%) received a 1-month extension of the initial phase, and of the 30 patients still smear-positive at 3 months there were no culture results available. Final treatment outcomes were similar, regardless of smear conversion at 2 or 3 months.

CONCLUSION

Certain characteristics were risk factors for failure to smear convert at 2 months. However, treatment outcomes for all patients were good. These findings have implications for the modification of national programme recommendations.

Delayed gastric emptying rates and impaired antral motility in children fulfilling Rome III criteria for functional abdominal pain

BACKGROUND

Gastric sensorymotor dysfunctions have been implicated in the pathophysiology of some functional gastrointestinal disorders, such as functional dyspepsia and irritable bowel syndrome. Therefore, we hypothesized that abnormal gastric emptying and impaired antral motility are possible underlying mechanisms of symptoms in children with functional abdominal pain (FAP).

METHODS

Hundred and two children [37 (36.3%) males, 4-14 years, mean 7.8 years, SD 2.7 years] fulfilling Rome III criteria for FAP were recruited for this study. An age and sex compatible group of healthy children (n = 20) were selected as controls [8 (40%) males, 4-14 years, mean 8.4 years, SD 3.0 years]. Liquid gastric emptying rate (GER) and antral motility parameters (amplitude of antral contractions, frequency of antral contractions and antral motility index) were assessed using a previously reported ultrasound method.

KEY RESULTS

Average GER (42.1% vs 66.2% in controls), amplitude of antral contractions (56.5% vs 89%), frequency of contractions per 3 min (8.5 vs 9.3), and antral motility index (4.9 vs 8.3) were significantly lower in patients with FAP compared with controls (P < 0.01). Fasting antral area was higher in patients (1.4 vs 0.6, P < 0.0001). GER negatively correlated with the scores obtained for severity of abdominal pain (r = -0.29, P = 0.004).

CONCLUSIONS & INFERENCES

Gastric emptying rate and antral motility parameters were significantly impaired in patients with FAP and GER negatively correlated with symptom severity. These findings highlight the possible role of gastrointestinal motility abnormalities in the pathophysiology of childhood FAP.

Developmental interventions in infancy during lengthy hospitalizations

A review of concepts related to infant development, care, and stimulation is presented. A description is provided of the development of an infant with small bowel syndrome during her hospitalization from birth until age 19 months. Interventions which facilitated feeding, sitting, walking, fine motor and language development are described. In addition, interventions are reviewed which focus on enhancing the infant's attachment to her cartakers, object permanence, and object constancy, and helping the normal unfolding of the individuation process. Efforts to "normalize" the hospital environment for the infant are stressed. The implications of the infant's hospitalizations and her future psychological development are discussed.